Some guidelines (eg. NCCN - National Comprehensive Cancer Network) suggest that men with small amounts of Gleason 4 (these are men with ISUP GG 2) on their biopsy can go onto active surveillance if other factors are suitable. But not much is known about long-term outcomes compared to that in men in the low risk Gleason score 3+3/Grade Group 1 group.

This study looked at the outcomes of both groups, but for men treated with surgery, to see if the cancer outcomes were equivalent. This is a roundabout way of seeing if active surveillance is safe in men in ISUP GG 2.

The findings showed that 94% of low GG1 and 83% of GG2 had prostate cancer that had not spread beyond the prostate. Invasion into the seminal vesicles was present in 2% of GG1 and in 5% of GG2. Cancer in lymph nodes was seen in 0.3% of GG1 abnd 2% of GG2.

The need for further (radiotherapy) treatment in the future was 6% in GG1 versus 12% in GG2. Finally, PSA remained undetectable in 89% of GG1 and 81% of GG2.

It is very common to find ‘inflammation’ on a prostate biopsy – 60-80% of biopsies may show this. It has long been debated whether inflammation is a risk factor for future prostate cancer and this has been unclear. This study was not a clinical study, but rather an examination of the medical literature for all studies reporting this finding.

The presence of inflammation was associated with a lower risk of finding subsequent prostate cancer in 25 studies. Both ‘acute’ and ‘chronic’ inflammation were associated with a reduction in prostate cancer risk.

In this study, PSMA PET/CT was used to examine men who had measurable PSA readings after radical prostatectomy. Recurrent disease was seen on imaging in 55% of men (74 out of 134) with very low (0.2–0.5 ng/ml) PSA and in 74% (102/138) of men with low (>0.5–1.0 ng/ml) PSA.

Based on these findings it seems reasonable to perform PSMA PET/CT in men with early biochemical recurrence (measurable; PSA) , as it can help direct further treatment decisions. Predictors of a positive scan were PSA, current use of hormone treatment (ADT) and to a lesser extent ISUP grade group (Gleason score).

The Gleason score has been ‘replaced’ by the ISUP Group for the scoring of the agressiveness of prostate cancer on biopsy or after radical prostatectomy. See below for a descritpion of the new scoring system:

Active surveillance for prostate cancer – how often do we see no cancer on a second biopsy?

Role of Surveillance Biopsy with No Cancer as a Prognostic Marker for Reclassification: Results from the Canary Prostate Active Surveillance Study. European Urology Volume 73, Issue 5, Pages 706–712

In this study, men on AS for prostate cancer were re-biopsied (surveillance biopsies) as per protocol. On first surveillance biopsy, 32% of men had no cancer, 43% had cancer that was the same ISUP group (Gleason score) as the first biopsy, and 25% had a change in the score on their biopsy.

For those men who had no change or no cancer on the first surveillance biopsy, when they came to their second surveillance biopsy, 38% had no cancer, 44% had the same cancer as originally, and 17% were reclassified. A finding of no cancer on the second surveillance biopsy meant men were less likely to have an upgrading in their cancer in the future. This means that it may be possible to slightly relax the frequency of surveillance in men who have a surveillance biopsy without cancer. It also means that for active surveillance protocols, one size does not fit all, and the frequency of follow up for prostate cancer needs to be tailored for the individual.

If you would like to discuss active surveillance for prostate cancer, please ask you GP to contact Nick Brook and this can be arranged.

What is focal therapy of the prostate?

In some ways, prostate cancer treatment has fallen behind other cancers. Although robotic surgery is a less invasive way of removing the prostate than an open cut, we are still not at the stage of being able to target cancer cells or groups of cells, and leave behind other non-cancerous cells in the prostate. This focused, or focal, treatment could have advantages in that important nearby structures are less at risk of damage compared to an operation to remove the prostate.

One of the issues is that, for some men, prostate cancer can be a multi-focal disease, meaning that it can occur in multiple areas of the prostate. Others may just have one 'index' lesion that needs treating, and these people could be good candidates for focal treatment.

High quality imaging is key

The key is high quality imaging of the prostate. There have been steps in the right direction with the use of multiparametric MRI of the prostate- see
here and
here.

A well performed mpMRI read by an expert radiologist is a powerful tool in identifying areas of the prostate that need biopsy - see
here and
here.

Accurate biopsy is very important

If we can have accurate biopsy - see
here - and be confident that this is a true representation of the degree of prostate cancer present, then it is just a small step to say that we could apply treatment to a focused area of the prostate to reduce the side effects of treatment for some men. Ask your urologist if he or she offers software fusion biopsy of the prostate.

Potential avenues for focal prostate cancer treatment

Currently, there are various options for development of focal therapy:

1 - focal brachytherapy - see
here for more information about brachytherapy - which is essentially just brachytherapy applied to one side of the prostate

2 - High intensity focused ultrasound (HIFU) treatment. This has been used in the past to treat the whole prostate, and results were mixed. Although focal-HIFU is in theory a slightly different approach, a lot of work needs to be done before this could be an accepted treatment

3 - Focal laser ablation using photodynamic treatment. Here a compound is injected, which is taken up by abnormal cells in the prostate. A laser is fired that is specific for the compound, and the laser causes a reaction in the compound that kills the targeted cells. The idea is that normal cells are not affected

4 - Direct laser energy targeting of the abnormal area in the prostate. This is the simplest, most direct and elegant idea - the area that is known to be abnormal and cancerous (from the MRI and subsequent biopsy) is targeted directly by a laser fibre. This approach has been investigated and used by urologists at UCLA in the States, and may hold out promise for the future

Conclusion

As surgical treatments become more refined, we hope that an increasing number of patients will be offered focal treatments. It is important that your urologist is able to discuss and offer a range of treatment. Most important is that the treatment is the right one for you.